107206795-5-28-2024-24-AS-SPIY-D6DTLG-20240619144930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206795
Report Date: 05/28/2024
Date Signed: 05/28/2024 09:43:58 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/21/2023 and conducted by Evaluator Lissett Padgett

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20231221100747

FACILITY NAME:	BLOSSOM CREEKS ASSISTED LIVING		FACILITY NUMBER:	107206795
ADMINISTRATOR:	SAMRA, RAJVINDER K		FACILITY TYPE:	740
ADDRESS:	501 SOUTH APRICOT AVE		TELEPHONE:	(559) 598-9515
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	6	CENSUS:	DATE:	05/28/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rajvinder Samra, Administrator		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/ lack of care and/or supervision resulting in resident's injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) L. Padgett conducted an unannounced complaint visit. LPA met with Administrator Rajvinder Samra and explained the purpose of this visit was to deliver the findings of the investigation completed by the Department. LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.
Per records review, Resident (R1) was admitted to a hospital and diagnosed with a variety of illnesses and the x-rays yielded three fractures including an old left femur fracture, and new left distal femur and right oblique spiral fracture. It was reported that R1 had sustained a prior femur fracture at the facility. However, a medical records review of the prior hospitalization did not yield any fractures. Interviews with the facility administrators and caregivers did not provide an explanation for the R1’s fractures. They denied any falls, injuries, or physical abuse. Based on the interviews conducted and records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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